Call us toll free 1-877-TMI-8171

In our previous post, we provided a summary of how VBP is affecting SNF reimbursements throughout this fiscal year.  Penalties and bonuses were determined by CMS calculations based on SNF 30-Day All-Cause Readmission Measure statistics from 2015 to 2017, and next year’s reimbursements will be determined by this year’s re-hospitalization metrics. For this reason, reduction of readmissions is a top priority for SNFs.


Reducing readmissions is a full court press which relies on effective care coordination and transitions – from inpatient to outpatient and with a diverse set of players along the way (providers, patients, and caregivers).


These transitions also require successful transfer of information between medical providers (hospitals, SNFs, home care agencies, physicians, etc.) and between medical providers, patients and family/informal caregivers.


Here are some recommendations to reduce 30-day hospital readmissions:




Hospital / SNF Collaboration:


 Hospitals have been hit hard too by readmissions penalties, and they’ve given billions of dollars back to CMS in past years. They want collaborative partners who provides the best care, patient education, and follow through to reduce preventable 30-day readmissions. How could your SNF and referring hospitals work better together?


  • Invite hospitalists into your SNF, so they understand care transitions from your perspective. Determine best practices together.
  • Provide your referring hospitals with evaluations of the transitions from their facility to yours. (Poor discharge summaries and poor medication reconciliation can make your team’s job all the more difficult!)
  • Track and report on data for each of your care pathways (stroke, cardiac, diabetes, etc.) to demonstrate your ability to care for patients and keep them from readmitting.


Internal SNF team:


 SNFs are feeling pressure from both sides – to reduce lengths of stay AND reduce re-hospitalizations. (Neither of which is a direct indicator of good patient care, but don’t get us started on that topic.) What steps can your organization take to reduce patients’ likelihood of returning to the hospital within 30 days?


  • Assess your readmissions – which ones were necessary? Which were avoidable? Has the pressure to reduce length of stay affected your readmission rates? If so, how and what can be done?
  • Do root cause analysis on preventable readmissions to find system defects and care defects. Ask the right questions:
  • How do you know when a patient who has discharged from your SNF is readmitted to the hospital? How are you informed?
  • When do your readmissions typically happen? Are there patterns in that data?
  • What types of patients are more likely to readmit?
  • Evaluate communication after discharge– Who makes follow up calls to patients? What set of questions is asked during that call? Does the frequency of patient follow up calls vary based on each patient (symptoms, knowledge, needs)?
  • Gather data and report results to your team.
  • Prioritize possible improvements (this could be great fodder for PIPs).
  • Create educational programs for your own team to improve the system, care practices, and transitions.
  • Create educational content/modules/system for patients and caregivers for training while they are still in your SNF, as well as after they go home (online learning).
  • Foster interdisciplinary collaboration in process development and care coordination. What is the current relationship between nursing and therapy? How could it be improved?
  • Plan for the home environment from Day 1. Discharge planning starts as soon as the patient enters your building. What are the barriers preventing a patient from getting to the next level of care? What should the therapy team be doing in the SNF (and at the patient’s home) to make sure the patient is ready for their own unique home environment?


Home Care & Coordination with Physicians:


Collaboration between your SNF and its home care partners is vital, as is efficient interaction with patients’ physicians. Here are questions to ask:


  • Are home care patients opened within 24 hours of discharge from your facility?
  • Who opens each patient? When is the next follow up visit?
  • When do home care patients receive their DME?
  • Are patients provided with telecare/telehealth units?
  • Are patients provided physicians’ appointment reminders with ample lead up time?
  • Are physicians alerted if patient values are out of range?
  • How are adjustments to medications managed?




For patients and their caregivers, the process of moving through the continuum of care can be overwhelming. Each care transition and environment can be new, jarring, and full of uncertainty for the patient. Their functional capabilities have changed, and they must learn new self-care practices.  What considerations and activities should be carried out with patients and their family/informal caregivers? 


 While in your facility, employ training strategies with patients, so they learn to self-monitor, know what to expect with their situation/condition, and respond accordingly (e.g. teaching CHF patient to manage weight and adjust diuretics).

  • Provide education on vital signs, ADLs, coping skills, signs & symptoms.
  • Ensure that education provided by your team is reinforced and expounded upon by your home care agencies’ teams.
  • Teach adaptive approaches to patients and caregivers. Returning home after a SNF stay can involve many life changes, which probably weren’t anticipated and/or prepared while in the SNF. However, you can help patients learn to evaluate and adapt to their changing conditions.
  • Encourage open communication between patients & caregivers and your team. Make sure they know who to contact at your facility to get their questions answered.
  • Follow up with discharged patients a timely intervals (before and beyond the 30 day mark) to assess their condition, and remind them of your concern for and dedication to their ongoing health and wellbeing.


 Whew, that was a lot to digest and is just the tip of the iceberg!  If your SNF has implemented successful initiatives that you’d like to share, please email me.



If you would like to talk about how your next therapy provider could work as a true partner with your organization to evaluate and reduce re-hospitalizations, we are here and ready for that conversation.